Introduction
Communication is crucial in ensuring patients understand instructions, warnings, and other significant details that can help enhance their quality of life. This review will identify practices in the United States that enhance the access to healthcare and language services to refugees with limited English proficiency (LEP). Examining the current status of US refugees and their healthcare experiences is crucial for providing a comprehensive understanding of the topic.
Background
Definition of Refugees
Every day, people in many countries face one of the most difficult decisions in life: to leave their homes. There are numerous reasons why individuals around the world want to start a new life in another country. Some leave home for a job or education, others are fleeing due to persecution or human rights abuses such as torture. Refugees are people who have fled their country because they have been disadvantaged due to race, religion, nationality, political opinion, or membership in a particular social group.
Statistics
Despite the relative geographic distance of the United States from the epicenter of today’s refugee crisis, it directly affects US immigration policy. The Executive Office, for example, significantly increased the total number of refugees admitted for resettlement in the United States, from 83,000 in 2020 to 96,000 in 2023 (Alola, 2019). Historically, the number of refugees admitted to the United States has varied from year to year.
Nevertheless, the number of refugees is rapidly growing nowadays; however, not all individuals manage to obtain a legal residence permit. Of all the countries on the list, Ukraine has the lowest percentage of refusals, with 6% of refusals and 48% of approvals (Alola, 2019). The statistics of approvals differ; nevertheless, it is clear that the percentage of refugees in the US is rising.
There is a large number of refugees in the United States, and they have very diverse needs. According to the United Nations High Commissioner for Refugees (UNHCR), the US has one of the highest numbers of refugees in the world (Feinberg et al., 2020). As of 2020, there were approximately 26 million refugees worldwide. In the same year, more than 79,000 refugees and asylum seekers arrived in the US alone, with approximately 60 percent being LEP (Feinberg et al., 2020).
Factors of Immigration
The number of refugees residing in the United States can fluctuate depending on the political stability of other nations and the severity of the problems these individuals face. Globally, countries have a wide range of procedures and legal requirements that can either encourage or discourage individuals from seeking asylum. The United States serves refugees from many countries worldwide, including Afghanistan, Syria, Iraq, Somalia, and others. The racial and ethnic variability of refugee populations may pose challenges for the US healthcare system in addressing their unique healthcare needs, including language and cultural barriers (Feinberg et al., 2020). While Language Access Services (LAS) and culturally appropriate care are essential for all refugee populations, the specific needs and challenges may vary based on the refugees’ country of origin and cultural background.
Health Challenges of Refugees
Language barriers, cultural differences, subjective ideas about health and illness, and racial or ethnic discrimination by service providers cause the vulnerable position of migrants regarding access to health care in the host society. Regardless of the specific demographic being studied, two consistently significant aspects of migration have a substantial impact on health as a social determinant. They include effects of migration on the health of migrants and individuals who reside or work in proximity to migrants (Kang et al., 2019). Moreover, migration impacts the work of doctors and the entire healthcare system.
Migrants often face challenges in navigating the healthcare system in their new country, particularly if they lack knowledge of its workings. However, certain groups of migrants, such as those who arrived for educational purposes and those who are reunited with their families, may find it somewhat easier to access healthcare (Brandenberger et al., 2019). Some migrant groups have almost no opportunity to seek medical care in time. Moreover, it is not profitable for employers or even non-profit social services, which results in intentional withholding of information. Healthcare providers and politicians have scant information to make decisions about this population.
Cultural Experience
Cultural Stress
Refugees are a special target group characterized by many social and cultural problems that become barriers to health care. Numerous migrants face language barriers and a lack of understanding regarding their approach to healthcare (Kang et al., 2019). Due to a lack of treatment facilities and, in part, inadequate coverage, medical services are not fully available during the asylum procedure.
Furthermore, complaints are often exacerbated during the current asylum procedures due to long, uncertain waiting times and difficult accommodation situations. New immigrants with limited or no knowledge of healthcare specifics often struggle to communicate or understand the doctor (Brandenberger et al., 2019). Moreover, there are other cultural differences and misunderstandings. These lie, for example, in a different understanding of the roles of men and women or insufficient knowledge of treatment methods, structures, and responsibilities in healthcare.
Causes
Cultural stress is related to the fact that migrants face a different system of values, language, culture, and traditions, ignorance and misunderstanding of which can lead to conflicts. Some refugees are indoctrinated with the idea that only complete assimilation and loss of cultural identity, national norms, and practices will allow them to build a new, successful life similar to that demonstrated by members of the cultural majority. Such an approach leads to the development of a state of stress and a complete fear of seeking any kind of help, including medical help.
Consequences
Communication barriers can hurt healthcare, especially among LEP refugees. Among refugees coming into the US, a significant proportion are LEP, with language barriers being a major impediment to healthcare access. Language proficiency, or lack thereof, affects health literacy because patients are less likely to follow physician directives if they need help understanding the provided procedures. LEP refugees often experience communication barriers, difficulty understanding medical information, and limited access to healthcare services, leading to poor health outcomes (Feinberg et al., 2020). LEP and health literacy are crucial factors that impact the ability of refugees to lead a healthy life when seeking or receiving care.
Trends in Care Seeking Behavior
It should be noted that migrants typically spend a significant amount of money on their journey. Given the above, it is understandable that treatment in private hospitals becomes inaccessible to them. It creates conditions for self-treatment and self-treatment, turning to unlicensed underground doctors and pre-medical workers (paramedics or nurses). As a result, the disease progresses to neglected and complicated cases of illness, which leads to calls to the emergency departments and often leads to the death of the migrant.
A considerable number of undocumented immigrants die without being recorded in official death records, and their remains are sometimes buried in unsuitable locations like forests or garbage dumps. Irregular migrants are unable to seek medical attention as they lack the necessary legal documentation to stay in the country. As a result, the mortality rate for various diseases among illegal migrants is high, with estimates reaching up to 30%. (Omenka et al., 2020).
There is a significant number of undocumented migrants who pass away without being accounted for in official mortality records. In some cases, their remains are interred in unsuitable locations, such as forests or landfills. Some groups have almost no opportunity to seek medical help promptly. It is not economically profitable for employers or even social services, which leads to the deliberate withholding of information. It fosters a particular behavior because migrants often seek unofficial medical care, which is carried out voluntarily.
Challenges Faced by Refugees
Language Barrier
In a new linguistic environment, even someone who knows the local language very well often gets lost. When contacting medical institutions, migrants often encounter instances of miscommunication between doctors and patients, which can impact the diagnosis and treatment prescription, and in some cases, lead to unintentional errors by doctors. Additionally, hospital situations may not always permit a companion fluent in the language to be present with the patient and serve as an interpreter (Origlia et al., 2019).
Poor Living Conditions
The living conditions of migrants are also a recognized factor influencing health. The main problems are housing that fails to meet sanitary standards, overcrowding, and inadequate ventilation systems.
Psychological Stress
There is a psychological obstacle that affects the health of migrants, and it has recently become more significant. Relocating to a new country for permanent residency can have a significant impact on an individual’s mental and physical health, resulting in stress and the potential development of psychosomatic illnesses (Assi et al., 2019). Even the usual paperwork for immigration often causes severe changes in the psyche, stress, diseases, and panic attacks.
Strategies to Overcome Challenges
Cultural
Providing culturally appropriate healthcare is essential to healthcare delivery, particularly for LEP refugees, who face numerous barriers to accessing healthcare services. Culturally relevant healthcare involves recognizing and respecting patients’ cultural beliefs, practices, and values and tailoring healthcare services to meet their specific needs (Matlin et al., 2018).
Language
Language access services and support play a key role in ensuring the delivery of culturally appropriate healthcare for LEP refugees by facilitating effective communication between patients and the healthcare team. For example, refugees are likely to experience greater challenges if they speak a language that their healthcare team is not fluent in; this suggests that the US healthcare system may need clear strategies to address these language barriers (Bang et al., 2023). Language access services should be provided to individuals with limited English proficiency, especially in healthcare settings, to ensure that language barriers do not.
As is now commonly believed, every migrant goes through three stages of psychological adaptation to the new country: euphoria, depression, and activation. The inability to explain one’s needs due to a language barrier leads to misunderstandings between the doctor and patient. Thus, language barriers undoubtedly affect the quality of care. Often, migrants experience great discomfort in receiving care, which remains a huge problem.
Challenges Faced by Providers
Language Barrier
A lack of interpreters or staff often hampers providers in today’s healthcare system. Nationals are the primary caregivers, but without interpreters, the patient and the doctor cannot communicate effectively. Moreover, people from certain countries may be particularly uncomfortable due to their cultural background (Assi et al., 2019). In some countries, particular sensitivities arise when prescribing medications that are not considered acceptable in certain cultural or social contexts. Often, helping a man to help a woman from another culture escalates into a cultural conflict.
Lack of Resources
The lack of funding and laws to promote the practice makes it practically impossible for refugees to fully access health services. In addition, the lack of education of providers on the specifics of working with different cultures and post-traumatic syndromes adds to the problems for migrants. Thus, staff need in-depth education. Additional funding and special legislation regulating migrants’ access to health care are needed.
Summary
Providers face many challenges while treating LEP refugees, such as language access, cultural differences, and different belief systems. Various organizations, including public health clinics, community health centers, and hospitals, provide healthcare for refugees in the U.S. However, US healthcare providers face several challenges when caring for refugees, including a lack of training on refugee health, limited resources for hospital staff, and inadequate language access services and support (Khullar & Chokshi, 2019). Providers may need to be made aware of refugees’ unique lifestyles and struggles, and should familiarize themselves with their cultural beliefs and practices. As a result, providers may struggle to deliver culturally appropriate healthcare, leading to dissatisfaction and mistrust among refugee patients.
The Impact of Provider Challenges
Global population migrations have multidimensional socioeconomic consequences, bringing resources and challenges to healthcare development. The multiplication and diversity of newcomers in receiving countries have expanded and restructured the demand for healthcare services. The resulting transformation of the health sector, including the development of a specific segment of health care adapted to the needs of migrants, increases the needs of recipient societies for health professionals, including those with knowledge of sociocultural morbidity and healing (Origlia et al., 2019).
Mass flows of asylum seekers in less-developed regions seriously strain local health systems, prompting humanitarian organizations to form a parallel healthcare segment for displaced people. These problems, exacerbated by the difficulty of employing health professionals abroad, contradict the popular argument that migration contributes to more efficient use of resources on a global scale. To mitigate the negative effects of health worker outflows, a system for managing their movements globally is needed.
Conclusion
Language access barriers in healthcare can create significant challenges for LEP patients and may result in health disparities. Culturally appropriate healthcare (which includes language access) recognizes the importance of addressing cultural values and practices in healthcare delivery to provide respectful and responsive care. For LEP refugees in the US, language access services and culturally appropriate healthcare are particularly crucial in ensuring that they receive quality care tailored to their unique linguistic and cultural needs (Matlin et al., 2018). By providing language access services and culturally appropriate care, healthcare providers can improve health outcomes for LEP refugees and reduce health disparities.
Research Gaps
Although practices, interventions, resources, and guides are available worldwide for culturally appropriate healthcare that meet LAS needs, it is unclear which practices are available or most effective in the US for its unique refugee population. This systematic review aims to fill this gap by identifying practices that have addressed barriers to healthcare and alleviated access to language services for LEP refugees living in the US.
Research Question
What healthcare practices enhance healthcare and language access services for refugees with Limited English proficiency in the US?
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